Provider Demographics
NPI:1588672950
Name:JOHNSON, JOHN KENNETH (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KENNETH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-1626
Mailing Address - Country:US
Mailing Address - Phone:608-786-2791
Mailing Address - Fax:
Practice Address - Street 1:700 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4783
Practice Address - Country:US
Practice Address - Phone:608-791-4186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist